Parent Statement & Insurance Verification

Participation in athletics is voluntary. It is important to realize that there is a possibility that catastrophic injury may occur due to athletic competition. The Cumberland County School District has an insurance policy (non-duplicating), which covers injuries sustained while involved in school athletics. This policy will pay only for medical expenses not covered by your own health insurance coverage. A sample of the policy BENEFIT PACKAGE AND LIMITATIONS is available through the Cumberland County School District Athletic Department.

This is to certify that I have read the statements on this card and hereby give permission for my child to participate in the sport named.

* Home Phone

Work Phone

Cell Phone

* Contact Person

* Relationship to Athlete

* Telephone No.

* Please state any medical information school personnel should have in case of emergency

* Physical Limitations

* Allergies

* Medications

Other

* Family Physician

* Telephone No.

Signatures

Student Athlete

Print Name:

Signature:

Date:

Parent / Guardian

Print Name:

Signature:

Date:

My signature indicates that to the best of my knowledge, my answers and information provided to the above questions are complete and correct. I understand that the information that I have provided on this form may be used for analytical and research purposes. I consent to the access and use of this data by the Cumberland County Schools, and Arbiter, LLC.